A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation. The results of the test indicate a negative CST.
Which of the following actions should the nurse take?

Administering opioid analgesics during active labor requires applying knowledge of pharmacology and maternal-fetal monitoring. The nurse must prioritize assessments that identify potential respiratory depression, cardiovascular changes, and the effectiveness of the medication while ensuring the safety of the fetus, which is sensitive to drug-induced changes.

Choice A rationale: Opioids cross the placental barrier and can cause decreased fetal heart rate variability or neonatal respiratory depression. Assessing the fetal heart rate before administration is critical to ensure the fetus is stable and not already experiencing distress that could be exacerbated.

Choice B rationale: Deep tendon reflexes are primarily assessed to monitor for magnesium sulfate toxicity or preeclampsia complications. Opioid analgesics do not typically affect these reflexes, making this assessment a lower priority compared to respiratory and cardiovascular monitoring during the active stage of labor.

Choice C rationale: Blood glucose monitoring is essential for clients with gestational diabetes but is not a standard requirement for administering opioid analgesics. The medication does not directly impact glucose homeostasis, so this assessment is not mandatory for the specific goal of pain management.

Choice D rationale: Opioids can cause maternal hypotension and respiratory depression due to their effect on the central nervous system. Monitoring blood pressure ensures the mother maintains adequate perfusion to the placenta, which is vital for the health and oxygenation of the fetus.

Choice E rationale: Assessing the pain level on a scale of 0 to 10 is necessary to establish a baseline and determine the need for medication. Post-administration assessment allows the nurse to evaluate the efficacy of the analgesic and the mother’s tolerance.

Complete the sentence: The nurse should massage the uterus and prepare to administer oxytocin.

Rationale for correct answers:
Uterine atony is the most common cause of postpartum hemorrhage (PPH), indicated by a boggy uterus and heavy bleeding with clots. Uterine massage stimulates uterine contractions, promoting involution and reducing bleeding. Oxytocin is a first-line uterotonic agent that increases uterine tone by stimulating smooth muscle contraction, helping to control hemorrhage. Normal hemoglobin is 11-16 g/dL; the client’s drop to 9.4 g/dL and hematocrit decrease to 27% (normal 33%-47%) indicate blood loss requiring prompt intervention.

Rationale for incorrect Response 1 options:
Inserting an indwelling urinary catheter is unnecessary here because the client emptied her bladder without difficulty, and urinary retention is not evident. Oxygen administration by nasal cannula is not indicated since the client’s respiratory rate is normal and there is no sign of hypoxia. Immediate oxygen is reserved for hypoxic or unstable patients.

Rationale for incorrect Response 2 options:
Administering oxygen by nasal cannula is not needed without hypoxia signs. Initiating a 1000 mL sodium chloride bolus might be considered later if hypovolemia or hypotension worsens but is not the immediate priority. Inserting an indwelling urinary catheter is not indicated as the bladder is emptying normally, and unnecessary catheterization risks infection.

Take-home points:

• Postpartum hemorrhage is primarily caused by uterine atony, presenting with a boggy uterus and heavy bleeding.
• Prompt uterine massage and administration of oxytocin are critical first-line interventions to control bleeding.
• Laboratory values such as hemoglobin and hematocrit help assess blood loss severity and guide management.
• Differentiation from other causes of bleeding (e.g., retained placenta, lacerations) requires assessment but initial treatment focuses on uterine tone restoration.